The Acute Abdomen

Andik Kusbiantoro

SMF Ilmu Bedah RSUD Dr.R.Soedjono Selong

Definition

• Acute abdomen describes clinical condition as result of emergency situations intra abdominal condition that needs immediate surgical intervention

• with pain as main symptom

Introduction

• Challenge to Surgeons & Physicians• Most common cause of surgical emergency

admission• Clinical course can vary from from minutes to

hours to weeks.• It can be an acute exacerbation of a chronic

problem.

Assesment

• Well elicited history• Proper physical examination Diagnosis can be made most of the time by Diagnosis can be made most of the time by

a good history and a proper physical a good history and a proper physical examination.examination.

Assesment (cont…)

Investigations are usually carried out :• only to support the diagnosis.• or to narrow down the differential

diagnoses.

History

• History of Present illness• Family history• Past medical history• History of drugs taken or Medication eg.

ingestion of certain toxic drugs or Alcohol intake

Drug history

• Corticosteroids – mask pain• Anticoagulants – can lead to an intramural

haematoma of the gut causing obstruction• Oral Contraceptives - rupture of hepatic

adenomas• NSAIDs - erosive gastritis & peptic ulcers

Other history• Past surgical history: previous operations- leading

to adhesions• Past medical history: Sickle cell disease, Diabetes

or Cancer or Renal failure• Menstrual History in females

– Missed period- ectopic pregnancy– Mid of period-ovulation pain (Mittel- schmerz)– With heavy periods- endometriosis

• Family history of colon cancer, any other malignancy or inflammatory bowel disease

Pain The Most Important Symptom

History of pain should include:1. Onset2. Severity3. Type of pain4. Radiation of Pain5. Change in nature of Pain6. Associated bowel or urinary symptoms7. Aggravating or relieving factors

Onset of Pain (cont…)• Sudden onset pain which wakes the patient from sleep eg. perforation or strangulation of bowel• Slow insidious Onset a. Inflammation of visceral peritoneum. b. Contained process such as evolving abscess.• Crampy or colicky pain

Biliary colic, Ureteric colic or Intestinal colic

Progression of Pain (cont…)

Progression from : Dull, aching, poorly localized character

To:Sharp, constant & better localized painindicates involvement of Parietal peritoneum

Table 1. Sensory innervations of intra abdominal structures

Structure Nerve LevelMiddle part of Diaphragm

Phrenicus C 3-5

Edge of diaphragm, stomach, pancreas, gall bladder, intestine

Plexus celiac Th 6-9

Appendix,proximal colon

Plexus mesentericus Th 10-11

Distal colon, rectum, kidney, urethra & testis

Splanchnic caudal Th 11-L 1

Vesica urinary, recto sigmoid

S 2-4

Figure 1. Innervations of diaphragm and shoulder

Figure 2.Referred pain and shifting pain in the acute abdomen

Referred Pain

Shifting Pain

Abrupt, excruciating pain Rapid onset of severe, constant pain

Gradual, steady pain Intermittent, colicky pain with free interval

Figure 3. The location and character of the pain are useful in the differential diagnosis of the acute abdomen

Colic billier

Colic ureter

IMA

Perforated ulcer

Ruptured aneurysm

Acute pancreatitis

Mesenteric thrombosis, strangulated bowel

Ectopic pregnancy

Acute cholecystitis, acute cholangitis, acute hepatitis

Appendicitis, salpingitis

Colic billier

Early pancreatitis (rare)

Small bowel obstruction IBD

Nausea & Vomiting

• Frequency of vomiting• Character of vomiting:

projectile, non-projectile or self-induced• Nature of vomiting: a. Bilious vomiting of small bowel obstruction b. Non-bilious vomiting in obstruction proximal to ampulla of vater c. Faeculent vomiting in distal small gut obstruction, large bowel obstruction , strangulation

Nausea & Vomiting

• Pain first, followed by Vomiting is usually surgical.

The vomiting is due to ‘reflex pylorospasm’• Nausea & vomiting first , followed by pain is

usually due to a medical condition

Urinary Symptomswith Pain

• Ureteric colic • Cystitis

Table 2. Physical findings with various causes of acute abdomen

Conditions Helpful signPerforated viscous Scaphoid (early), tense abdomen, diminished

bowel sound (late), loss of liver dullness, guarding or rigidity

Peritonitis Motionless, absent bowel sound (late), rebound tenderness, guarding

Inflamed mass or abscess Tender mass, special sign (Murphy's, obturator or psoas)

Intestinal obstruction Distention, visible peristaltis (late), hyperperistaltis (early) or quiet abdomen (late), diffuse pain, hernia (some)

Paralytic ileus Distention, minimal bowel sound

Ischemic or strangulated bowel

Not distended (until late), severe pain, rectal bleeding (some)

Bleeding Pallor, shock, distention, pulsatile (aneurysm)

Figure 3. Causes of shock in patients with acute abdomen

Consideration of Surgery Intervention

• Decision of surgery intervention on acute abdomen depends on correct diagnosis. If we got difficulties to make decision, we should observe patient closely.

• Meanwhile patient must fasting, apply naso gastric tube and IV line

Table 3. Indications for urgent operations in patients with acute abdomen

Physical findings Involuntary guarding or rigidity, especially if spreading Increasing or severe localized tenderness Tense or progressive distention Tender or abdominal or rectal mass with high fever or hypotension Rectal bleeding with shock or acidosis Radiologic findings Pneumoperitoneum Gross or progressive bowel distention Free extravasations of contrast material Space occupying lesion on scan, with fever Mesenteric occlusion on angiography

Summary

• Acute abdomen is serious surgical emergency requiring the surgeon to combine the result of the history and physical examination with properly selected laboratory and radiographic studies

• Correct preoperative diagnosis will usually lead to a successful operation

Physical Examination

General Appearancea. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitisb. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colicc. Writhing in Pain: Mesenteric Ischemia

Physical Examination (cont...)

d. Bending Forward: Chronic Pancreatitise. Jaundiced: CBD obstructionf. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction

Physical Examination (cont...)

• Vital Charting• Temperature, Pulse, BP, Respiratory rate• Ruptured AAA or ectopic pregnancy can lead to -Pallor -Hypotension -Tachycardia -Tachypnea

Physical Examination (cont...)

Low grade temp. is seen with - Appendicitis- Acute cholecystitis

High grade temp. is seen with - Salpingitis- Abscess Very High Grade Temp.with increasing lethargy

seen in imminent septic shock- Peritonitis- Acute cholangitis- Pyonephrosis

Extra abdominal conditions that causes abdominal pain

• These may rarely present as referred abdominal pain.

• The most important to remember :– Pneumonia (especially lower lobe) – Myocardial Infarction.

• Those diseases tend to be “ Medical” diseases and surgery is not generally indicated

Systemic Examination

Cardiopulmonary examination Check for: - Possible MI - Basal Pneumonia - Pleural Effusion

Systemic Examination

Per Abdomen: Inspection

- Scaphoid or flat in peptic ulcer- Distended in ascites or intestinal obstruction- Visible peristalsis in a thin or malnourished

patient (with obstruction)

Systemic Examination

Per abdomen:Palpation

• Be gentle• Start away from site of pathology then towards• Check for Hernia sites• Tenderness• Rebound tenderness• Guarding- involuntary spasm of muscles during palpation• Rigidity- when abdominal muscles are tense & board-

like. Indicates peritonitis.

Systemic Examination• Local Right Iliac Fossa tenderness: a. Acute appendicitis b. Acute Salpingitis in females c. Amoebiasis of Caecum• Low grade, poorly localized tenderness: Intestinal Obstruction • Tenderness out of proportion to examination: a. Mesenteric Ischemia b. Acute Pancreatitis• Flank Tenderness: a. Perinephric Abscess b. Retrocaecal Appendicitis

Systemic Examination

• Rovsing’s Sign in Acute Appendicitis• Obturator Sign in Pelvic Appendicitis• Psoas Sign

– Retrocaecal appendicitis– Crohn’s Disease– Perinephric Abscess

• Murphy's sign in Acute Cholecystitis

Systemic Examination

Per Rectal Examination: - tenderness - induration - mass - frank blood

Investigations

• Complete Blood Count with differential• C-reactive protein estimation• Electrolyte, Blood Urea, Creatinine• Urine dipstick• Amylase or Lipase• Liver Function Test

Radiology

Chest x rayAbdominal x ray

Investigations

Other Investigations- USG- CT abdomen for AAA, Pancreatic disease,

or ureteric colic (non- Contrast)- IVU- Mesenteric Angiography for Ischaemia, Haemorrhage

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